Key words: Cigarette smoking, cessation patterns, students, Tabouk, Saudi Arabia.
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INTRODUCTION

Health education programs, mass media campaigns and nowadays even the slogans depicted on cigarette packages, warn smokers about the harmful effects of smoking. Despite all these efforts people continue to smoke1-3. Smoking among adolescents is on the increase worldwide and particularly in developing countries including rich developing countries such as the Kingdom of Saudi Arabia. Smoking surveys in the Middle East showed that smoking prevalence among young people ranged from 7% in Oman to 53% in Lebanon with 25% in Saudi Arabia4. Prevalence of smoking among adolescents appears to be rising, with more children and adolescents becoming regular users of tobacco each day. It has been estimated that 15% - 30% of Saudi adolescents smoke. Expenditure on tobacco imports is a significant burden on economic development. Saudi Arabia currently imports 20,000 million cigarettes per year, which costs $351.8 million4. Serious complications of smoking usually occur later in adult life but even at youth age there are numerous adverse health conditions caused by tobacco use including reductions in the rate of lung growth and in the level of maximum lung function, increase in the number and severity of respiratory illnesses and unfavorable effects on blood lipid levels5. In Saudi Arabia cigarette smoking was the main risk factor for acute myocardial infarction in young age patients6. Evidence shows that four out of every five persons who use tobacco begin before they reach adulthood, becoming addicted early, making them less able to quit and more likely to be affected by a tobacco-related health problem7. The longer the onset of smoking behavior is delayed, the less likely the person is to become addicted. Once addiction occurs, however, nicotine dependence is extremely difficult to break. Hence it is of paramount importance that tobacco-preventing activities should focus on school-age children and adolescents to reduce future smoking-related illness and associated costs. The literature on smoking cessation among the population of adolescents is sparse and very little research has focused on the problem of teenage smoking cessation. Better understanding of the problem of cessation is needed to provide an empirical basis for the development of effective programs that encourage teenagers to quit smoking.

The general aim of this study is to provide baseline information regarding tobacco cessation patterns and factors associated with smoking quitting attempts and their outcome. To the authors best knowledge this is the first study of its nature and scope to be conducted in Tabuk area in Northern Saudi Arabia with the intention of utilizing the generated information in designing, implementing, monitoring and finally evaluating a comprehensive tobacco control program including cessation strategies.

METHODS

This is a cross-sectional school-based study in Tabouk Governmental schools with grades 7 through to 12 (intermediate and secondary schools), corresponding to age 12 to19 years. This was preferred to the household survey because it is logistically easier, cheaper, and gives more freedom for students particularly females to express their habits and views away from family pressure. Two-stage stratified cluster sampling method was used. All public schools consisted of grades 7 to 12 in Tabouk city and were placed firstly in two categories according to school level (Intermediate schools and Secondary schools). Secondly, each category was stratified into two categories according to sex. In the first stage 16 schools were randomly selected proportional to the enrolment size (four schools from each of the four categories: 4 intermediate boys, 4 intermediate girls, 4 secondary boys and 4 secondary girls. In the second stage, 3 classes were randomly chosen from each of the 16 schools, one from each grade. This yielded 48 classes with 1,566 students all of whom were included in the study. The mean class size for the whole group was 33 students and there were no obvious differences between male and females in this respect.

The study tool used was an anonymous, pilot tested, self-administered questionnaire consisting of 56 questions, with core items selected from Global Youth Tobacco survey items (Arabic version). The Questions were grouped into categories relating to tobacco use, prevalence of tobacco use, access to tobacco, knowledge and attitude toward smoking, attitude toward cessation of smoking, exposure to environmental tobacco smoke, exposure to tobacco related advertisements in media, and education on tobacco and smoking in school

Questionnaires were distributed during the mid-morning classes to avoid eliminating students arriving late and also to avoid lunchtime. The collection of data was conducted under the supervision of health care workers in schools in the absence of any school teacher or any other school personnel. Confidentiality was assured (written and verbal) and that data will be used only for the stated research purposes.

The heath workers were responsible for the delivery and collection of all the survey documentation forms and for reporting the number of students not attending class on the date of the survey, or refusing to participate in the survey. Completed questionnaires were collected and checked manually for completeness and then entered into a personal computer and analyzed using SPSS package version 11.5. Descriptive analysis was performed to compare between the two sexes. Statistical associations between current smoking status and study variables were tested with chi-squared distribution. The level of significance was set at P < 0.05.

Definitions
The following definitions were used to characterize the smoking status.
Ever smoker: any student who had ever smoked cigarettes, even one puff.
Current cigarette smoking: having smoked on one or more days in the 30 days preceding the survey.
Ex-smoker: ever smoker who had not smoked in the 30 days preceding the survey.

RESULTS

Of the total 1,505 students who completed the questionnaires (98% response) 657 (43.7%) were ever smokers. Of the ever smokers 523 (79.6%) tried seriously to quit and the rest (134 - 20.4%) never attempted to quit. About 70% had more than two attempts. The most important reason for attempting quitting was health concerns in 62.4%, family pressure for 23.9%, friends' pressure for 6.3% and only 2.4% to save money. A quarter of the smokers self initiated their quitting attempt. The majority had assistance from family (36.4%), or from friends (22.1%) and less than 17% from antismoking programs. Table 1 shows characteristics of these two groups (who did not attempt and who attempted quitting) Smokers who did not attempt to quit tend to smoke more cigarettes, buy their cigarettes, have positive attitudes towards smoking and were more exposed to tobacco environmental smoke in homes and public places. Of all ever smokers who attempted to quit 321 (61.4%) were successful so far (ex-smokers) for cessation periods ranging from one month to three years. Less than 7% (36 smokers) tried seriously and were successful initially but relapsed and 166 (31.7%) smokers tried and were completely unsuccessful. So at the time of the study of all ever smokers 321 (48.9%) were not currently smoking (quitters/ex-smokers) and the remaining 336 (51.1%) were continuing smoking (current smokers).

Table 2 shows data on personal characteristics of current smokers and ex-smokers. A significant difference was observed for age when first tried cigarettes, pocket money and whether parents smoke. Those with more pocket money (> 20 SR) (OR = 14.27), with parents who both smoke (OR = 1.86), father only smokes (OR = 1.39), mother only smokes (OR = 1.67) and those with elder age (> 15) when they first tried smoking (OR= 1.54) are more likely to continue smoking. Table 3 shows attitude and practice of current smokers and ex-smokers. A significant difference was detected for smoking is harmful to health, number of friends who smoke, idea of one who smokes, exposure to smoking from others at home or in public places, those who own something with a cigarette logo in it and feeling more or less comfortable when smoking at celebrations or social gatherings. Those who think smoking is not harmful to health (OR = 1.89), with some friends (OR = 2.32) or all friends smoke (6.43), who think positively of smoking (OR = 3.57), those who were less exposed to smoking either at home (OR = 1.79) or in public places (OR = 2.39), those with something with a cigarette logo on it (OR = 1.85) and those who feel more comfortable when they smoke at celebrations or social gatherings (OR = 2.44) are more likely to continue smoking.

The results of the stepwise discriminant analysis are shown in Table 4. Wilks' lambda, as a test of discriminant function was highly significant (Wilks' lambda = 0.407; (2 = 593.6). In total the model classified 82.8% of the students included in the sample. Specifically, the model classified 76.3% of students continuing smoking and 88.5% of ex-smokers. The standardized coefficients indicate the relative importance of the discriminating variables in predicting the dependent variable. Based on magnitude of the standardized coefficients, number of friends who smoked, smoking parents, number of cigarettes smoked, smoking from others at home, idea from one who smokes, smoking harmful to health, and age when first tried cigarettes made the largest contribution when discriminating between smokers and ex-smokers. The positive signs of the coefficients for number of cigarettes smoked and number of friends who smoke, indicates that students with more friends who smoke and smoke heavily are more likely to continue smoking. The negative sign for the coefficients of the idea of one who smokes, smoking is harmful to health, age when first tried cigarettes and whether parents smoke or not, indicates that students with non-smoking parents, and those who tried smoking lately, those who know the harmful effect of smoking and those who are exposed more to cigarette smoking at home are more likely to be ex-smokers.

DISCUSSION

The results of this study showed that smoking is prevalent among adolescents in Tabouk. This is a serious situation because studies estimated that 50% of adolescents, males and females who started smoking as adolescents, will continue to smoke for at least 16 - 20 years8. This has serious morbidity and mortality and socioeconomic implications. The economic costs in terms of medical expenses and in lost productivity is huge9, but the good news is that the majority of adolescent smokers in Tabouk wanted to quit and most of them tried seriously. This is in accordance with the findings of international studies among smoking adolescents10-12. Studies showed that quit rates are affected by peers, friends or family members13-17. In the Arab culture, the family is the most important social unit and the reason for cigarette smoking for adolescents is initiation of family members and friends. Parental smoking history plays an important role in the early adolescent smoking behavior. More than 30% of the students in our study have been confronted with at least one currently smoking parent in their home. Parental smoking cessation has differential effects on adolescent smoking, depending on the age the child was when the parent stopped. Bricker among others 17-20 found that an adolescent child to be an ever smoker was higher when the father had quit smoking between the years 11 -14 compared to quitting before the child reached the age of 7 years.

Our findings that family environment may have a significant effect on quitting smoking are in harmony with other studies14,16,19. Adolescents who lived in a household with a greater proportion of smokers were less likely to quit. Our study revealed that about 36% of those attempted to quit smoke at home. More than 40% of those who attempted to quit smoking, their source of cigarettes were home and more than 30% of all members living in the same household smoke. Smokers in the immediate environment of the ex-smoker place nicotine-laden smoke into the local air space, which is inhaled by the ex-smoker and may create a return of the physiological reinforcement of nicotine or may create a conditional physiological desire to smoke. This suggests support from other members of the household may play a crucial role in quitting smoking; this together with availability of cigarettes during the quitting attempt. About 36% of adolescents in our study reported they received advice from family members to stop smoking. Similar percentage of male (80%) and female (78.6%) smokers have attempted to quit. This is surprising, as Muslim Arab males might perceive that smoking helps increase their masculine image among their peers and makes them appear more mature. On the other hand, Muslim Arab females might perceive that smoking affects their feminine Islamic images and reputation, thus affecting their prospect of a good marriage and therefore have a higher tendency to quit smoking. Other studies found little gender differences in overall quit rates20,21,22. This appears to indicate that cessation is not influenced by socio-demographic variables, suggesting that quitting may be motivated by reaction to the consequences of smoking itself. The age at which adolescents had first become regular smokers did not prove to be a strong predictor of smoking cessation. About 11% of ex-smokers tried cigarettes before the age of 10 and more than 70% tried between the age of 10 and 15. Percentages were comparable for ex-smokers and current smokers. International studies reported conflicting associations. The majority of studies found that smokers who initiated smoking at an earlier age were less likely to attempt quitting or be successful in their attempts, while others reported no significant association of age with quitting23,24. The influence of friends who smoke is significant for both the initiation and the maintenance of smoking. As an adolescent grows up, the peer influences become more important than family influence. Our results showed more than 80% of ex-smokers have none or only a few friends who smoke. Adolescents who had few friends who smoke, had fewer cigarettes offered to them and would be able to resist pro-smoking pressure. Our results showed that about 70% had more than three attempts. This contradicts the findings from other studies14,15,17 and indicates that peer pressure from smokers may deter quit attempts and that more time spent with smokers infers less time in non-smoking environments, resulting in fewer quit attempts. Other studies12,14,15,21 found that a friend's smoking, cigarettes offering and perceived pressure to smoke, correlates with increased smoking. On the other hand, individual factors such as self-efficacy to resist peer pressure and anti-smoking beliefs were important to prevent and stop adolescents smoking. Our results showed that cessation programs were contacted by only 17% of adolescent smokers. This needs to be further explored to try to make these programs known to all adolescent smokers and to them more attractive to young smokers. Some smoking cessation activities are conducted in Primary Health Care clinics by physicians and dentists. Those activities have been inconsistent in providing advice and counseling against smoking and are characterized by the use of different and sometimes ineffective methods for smoking cessation, such as the use of acupuncture. Studies in other countries have shown the key role that physicians can play in smoking cessation and strategies have been devised to encourage anti-smoking counseling by physicians. Research evidence supports that medical visits can provide an opportunity for tobacco intervention and should be used as an intervention method25. Physicians need to be non-smokers themselves and be trained to deliver effective cessation services. Studies conducted Riyadh showed that the majority (69.3%) of dentists were not confident in their skills in cessation activities for their youth patients. Some physicians question the effectiveness of their role in smoking cessation26 and some may lack the necessary skills and knowledge27. National guidelines for smoking cessation activities are needed. The majority of quitting attempts in other countries were self initiated, unprepared and unplanned28. The reasons for attempting quitting in Tabouk were mostly related to health considerations and family pressure in accordance with findings of previous studies in the country, which in addition to health concerns, religious considerations were remarkable29. Religious factors were not investigated in the current study in Tabuk. In studies outside Saudi Arabia religiosity was not a predictor of smoking30. In other countries in addition to health, price of cigarettes was also an important motive to quit31,32. It seems that smoking by youth is particularly sensitive to price and increased prices would be expected to deter young people from smoking. Price in the Kingdom was a motive for quitting in less than 5% of smokers. Price of cigarettes in the Kingdom is very cheap compared to income and is not expected to be a major anti-smoking motive. Increasing prices on cigarettes may be an important pathway to quit smoking. Body image and weight considerations were also important reasons for relapse in international studies particularly among females33,34. In Tabouk body image and weight were not significant predictors of quitting attempts and their outcome. School performance was not associated with quitting attempts and their outcome in Tabouk. Less than half of smokers in Tabouk who attempted to quit were successful quitters at the time of the study with quitting period of at least 30 days (range one month to three years). Studies showed that about one third of adolescent smokers were successful quitters at the time of the study 35,36,37. It is not known how many of them will become permanent quitters. Several studies reported approximately 3 out of 4 of every adolescent smokers have tried to quit smoking and have failed and that only 4 percent of young people at best are successful in their quit attempts each year38,39,40,41.

The findings from this study show that Saudi Arabia appears to face an enormous challenge in persuading smokers to stop smoking. Of the ever-adolescent smokers in Tabouk area the number who failed to quit and relapsed, exceeds the number of former smokers who have successfully quit. These findings should figure centrally in formulating smoking cessation programs. The high relapse rate indicates a need for effective methods for smokers for maintaining cessation. Nicotine replacement therapy and other pharmacologic approaches have not yet been widely used and these methods need specific evaluation in the Kingdom of Saudi Arabia.

The potential limitations of this survey are its use of self-reporting of cigarette smoking without biochemical validation and possibility of under- or over- reporting smoking habits. Religious considerations and some sociodemographic and economic factors should have been addressed. The survey findings call for a national strategy to increase smoking cessation activities with clear guidelines within a framework of a comprehensive plan and programmatic actions. This should include media campaigns to increase knowledge, education of health care and educational professionals to strengthen their role in encouraging and sustaining cessation, enhancing support from family and friends, and developing and evaluating smoking cessation methods. Programs to be effective and appealing to adolescents should center on internet and mobile phone messages as these are widely used by adolescents.

Table 1. Characteristics of smokers who attempted to quit and those who did no attempt quitting

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Table 2: Characterization of smoking habits according to students smoking contacts: Variable

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Table 3. Attitudes of ex-smokers and continuing smokers